- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,011.87 / $7,244.36
| Facility | | $4,677.35 | $5,011.87 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,818.38
| Professional | | $1,819.70 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,128.31 / $22,908.68
| Facility | | $4,265.80 | $8,128.31 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,467.37 / $8,709.64
| Facility | | $1,737.80 | $3,467.37 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $8,511.38
| Facility | | $1,584.89 | $3,467.37 | $8,511.38 |